| Complaint: | Complaint 21-63 |
|---|---|
| Respondent: | Katherine Goulbourn |
| Premises: | North Valley Pet Hospital |
The complaiannt tells that she brought her puppy in to North Valley Pet Hospital for a spay with Goulbourn. The puppy was "healthy, happy, and energetic" before the procedure but dead by the end of it; we're told that during the procedure the puppy's heart stopped and CPR was performed without success. Goulbourn herself allegedly investigated the death and determined that the anesthesia machine used was not connected; apparently, between surgeries, the system was changed to a different circuit and the oxygen hose was left unattached. Goulbourn is said to have concluded the dog died from lack of oxygen. The complainant says this was an act of negligence; she asks why nobody checked this before the surgery and wonders why pulse oximetry wasn't used during the procedure. She also has concerns that her dog was said to have "acted as though she was coming out of anesthesia"; in addition to the implied horrors of waking up in the middle of your own spay procedure, the complainant wonders if her dog was actually waking up because she had no oxygen. She wants North Valley Pet Hospital and Goulbourn held accountable.
Goulbourn says that the spay was the second surgery of the morning; the dog was brought into the surgery suite after being anesthetized by surgery staff. She tells us that Talya Briceno assisted her with the procedure. Goulbourn says that after she started cutting into the dog the dog started to breathe harder and began to have mild swallowing; fearing the dog was not knocked out enough she asked Briceno to take it up a notch. Briceno did so; Goulbourn also asked Briceno to check the machine because she couldn't see it, and Briceno allegedly said it was working correctly. The dog's breathing slowed and oxygen levels dropped so Goulbourn told Briceno to shut off the isoflurane; Briceno asked another staff member, Deseree Ruedas, to assist in monitoring. Ruedas jumped in to help and "discovered that the tubing connecting the oxygen flowmeter to the rebreathing circuit and scavenging system were not connected." Together they started CPR which had no effect; someone called the complainant (Goulbourn doesn't know who) and was told to only continue CPR if Goulbourn thought the dog could be revived. Goulbourn subsequently directed CPR efforts to be halted and told her boss, William Dean, what had happened. Dean told her that they would update their procedures to make sure the anesthetic machines were connected from now on. Goulbourn says that a statement from her assistant, Briceno, is attached (we don't get to read it); she also says that Ruedas, the staff member who pointed out the machine wasn't hooked up in the first place, no longer works at North Valley Pet Hospital. (It's also worth a read to see the number of specialty services that North Valley appears to offer; judging by the entries listed in the margin of the form letter, they're bigger than UC Davis, which is probably the closest thing pets in North America have to a real hospital.)
The Investigative Committee, in one of the most surreal investigations in the history of humankind, decided nothing was wrong here and voted to dismiss 3 to 1 (Almaraz voted no). They said that it was a "terrible tragic accident" and that mistakes just sometime happen; they also said they were "because they felt there was negligence but it was an accident." According to the Committee it was reasonable for the complainant to want someone to look into it, but they didn't do anything about it; they helpfully said that the clinic owned up to the mistake and paid for the dog's cremation. They also said that these kinds of events affect the veterinarians and staff too, so we should feel for them. The Board had other ideas and found Goulbourn guilty of gross negligence; they gave her a Decree of Censure, which is an otherwise totally ineffective punishment that goes on her record. As of early 2023 she's still working at North Valley Pet Hospital.
The three people on the Committee who voted to dismiss are all veterinarians and they all run their own practices, which is again somewhat disturbing if also par for the course. Dow's the top man at Prescott Animal Hospital and also had some relatively high-ranking roles within the Arizona Veterinary Medical Association. Sidaway's been all over the place and was the founding dean who helped get Midwestern University's veterinary school off the ground; he also ran Incise Veterinary Surgery, a mobile surgical service that morphed into a veterinary consulting firm, along with being the CEO of Desert Ark Veterinary Care. Amrit Rai runs Sugarloaf Animal Clinic. Does their vote here reflect their attitudes toward patient safety in their own shops?
The other sad fact about this is that in some ways this was all too predictable. North Valley had a variety of complaints filed against it but constantly dismissed or tossed out for one reason or another. In 19-03, Dean was cited in a complaint as responsible veterinarian; among other concerns the complainant suggested the entire place was a confused mess, but the investigators said they had no idea why she even complained. In 19-79 and 19-80 a (dying) cat was directed to another veterinary clinic 65 miles away; Dean and Goulbourn said the clinic was constantly overwhelmed with patients. And these are just the items that got to the point someone filed a complaint; we don't know about other incidents that never got reported anywhere. From the standpoint of an actual safety culture, such as in aviation, a pattern of little problems are usually considered a tell that a bigger problem could be likely to happen. If veterinarians, broadly speaking, had to fly to their next conference on an airline that used their own safety practices and ethics, they wouldn't board the plane.
| Source: | May 5, 2021 PM Investigative Committee Meeting |
|---|---|
| People: | |
| David Stoll | Respondent Attorney |
| Katherine Goulbourn | Respondent |
| Roll Call: | |
| Adam Almaraz | Nay |
| Amrit Rai | Aye |
| Brian Sidaway | Aye |
| Cameron Dow | Aye |
| Result: | Passed |
| Source: | June 6, 2021 Board Meeting |
|---|---|
| People: | |
| David Stoll | Respondent Attorney |
| Proposed By: | Robyn Jaynes |
| Seconded By: | Jane Soloman |
| Roll Call: | |
| Darren Wright | Aye |
| J Greg Byrne | Aye |
| Jane Soloman | Aye |
| Jessica Creager | Aye |
| Jim Loughead | Aye |
| Nikki Frost | Aye |
| Robyn Jaynes | Aye |
| Sarah Heinrich | Absent |
| Violations: | |
| ARS 32-2232 (11) Gross negligence | |
| Result: | Passed |
| Source: | Order 21063 (July 7, 2021) |
|---|---|
| Violations: | |
| A.R.S. § 32-2232 (11) gross negligence — treatment of a patient or practice of veterinary medicine resulting in injury, unnecessary suffering or death that was caused by carelessness, negligence or the disregard of established principles or practices — for failure to ensure that anesthetic equipment was in working condition and connected correctly prior to surgery. | |
| Penalties: | |
| Decree of censure | |
The primary source for the above summary was obtained as a public record from the Arizona State Veterinary Medical Examining Board. You are welcome to review the original records and board meeting minutes by clicking the relevant links. While we endeavor to provide an accurate summary of the complaint, response, investigative reports and board actions, we encourage you to review the primary sources and come to your own conclusions. In some cases we have also been able to reach out to individuals with knowledge of specific complaints, and where possible that information will be included here.